Gout and Hyperuricemia Day 1

Question 1

What is Gout?

Answer 1

hyperuricemia. It is recurrent attacks of aacute arthritis associated with urate crystals in synovial fluid. The crystals deposit in tissues in and around joints. It is an intestinal renal disease. It is uric acid nephrolithiasis

Question 2

What is the epidemiology of gout?

Answer 2

men>women
peak 30 - 50 years
“disease of kings”

Question 3

What are the risk factors of Gout?

Answer 3

older are
male
hyperuricemia
obesity
HTN
DM
CKD
Alcohol intake 
high red meat or fish intake

Question 4

What is the pathophysiology of uric acid?

Answer 4

produced from purine degradation. It is a waste product with no physiologic purpose

Question 5

What is the pathophysiology of uricase?

Answer 5

enzyme that breaks down uric acid into soluble allantoin

Question 6

What does hyperuricemia occur from?

Answer 6

overproduction of uric acid and underexcretion of uric acid

Question 7

What 3 sources do purines come from?

Answer 7

diet
conversion of nucleic acid to purine nucleotides
De Novo synthesis of purine bases

Question 8

What can cause an over production of uric acid?

Answer 8

purines and 2 enzyme abnormalities

Question 9

What causes under excretion on uric acid?

Answer 9

multiple factors

Question 10

How does uric acid get eliminated?

Answer 10

urine and enzyme break down in GI tract

Question 11

What is urine excretion determined by?

Answer 11

Glomerular excretion
tubular secreation
tubular reabsorption
postsecretory reabsorption

Question 12

What medications that decrease Uric acid excretion?

Answer 12

diuretics
nicotinic acid
salicylates
ethanol
pyrazinamide
levodopa
ethambutol
cytotoxic drugs
cyclosporine

Question 13

How do you evaluate hyperuricemia?

Answer 13

determine if over producer or underexcretor

Question 14

What determines if you are an underexcretor of uric acid?

Answer 14

purine free diet for 3-5 days and <600 mg/day excreted

Question 15

What determines if you are an overproducer of uric acid?

Answer 15

purine free diet for 3-5 days and >600 mg/day excreted

Normal diet with an excretion of >1000 mg/day

Question 16

What is the clinical presentation of acute gouty arthritis?

Answer 16

rapid onset (night)
excrusciating pain, swelling, inflammation, redness, fever
monoarticular early on (big toe, ankles, heel, wrist finger)
podagra
resolves in 3-14 days

Question 17

What are precipitating factors of Acute gouty arthritis?

Answer 17

stress, trauma, alcohol injestion, infection, surgery, rapid lowering of serum uric acid, medications

Question 18

What is the clinical presentation of atypical presentation?

Answer 18

chronic polyarticular arthritis

multiple small joints in hands

Question 19

What is the clinical presentation of Tophaceous gout?

Answer 19

late complications (10 yrs to develop)
urate crystals deposit in soft tissue
sites (helix of ear, wrist, hands, elbow, olecranon bursae, achilles tendon, base of big toe)
pain, tissue and joint damage and deformity, nerve complications

Question 20

What is the risk factors of uric acid neophrolithiasis?

Answer 20

overexcreter
acidic urine
highly concentrated urine

Question 21

What is uric acid nephropathy?

Answer 21

acute renal failure

urine flow blockage due to collection of uric acid crystals in collecting ducts and ureters

Question 22

What is chronic urate nephropathy?

Answer 22

long term deposits of urate in renal parenchyma

Question 23

What are the sign/symptoms of chronic urate nephropathy?

Answer 23

decreased ability to concentrate urine
proteinuria
HTN
Nephrosclerosis

Question 24

What is the only definitive diagnosis of gout?

Answer 24

synovial fluid aspirate containg urate crystals

Question 25

What do you need to consider for a clinical diagnosis for gout?

Answer 25

more than 1 attack of acute arthritis
max inflammation within 1 day
monoarthritis attack
redness over joints
1st metatarsophalangeal joint painful or swollen
nilateral 1st metatarsophalangeal joint attack
tophus
hyperuricemia
asymmetric swelling within joint on xray
subcortical cysts w/o erosions on xray
urate monohydrate microcrystals in joint fluid
joint fluid cultrue negative for organisms

Question 26

What are the diagnositic tools for gout?

Answer 26

radiograph (changes with long standing)

MRI and CT and not typical

Question 27

When do you use acute treatment?

Answer 27

for current gout flare

Question 28

When do you use chronic treatment?

Answer 28

frequent flares (>1/ year)
presence in 1 or more typhus
CKD Stage 2 or worse
history of urolithiasis

Question 29

What are the treatment goals of gout?

Answer 29

terminiate acute attack
prevent recurrent attacks (want serum uric acid <6)
prevent complications

Question 30

What are the non pharmacologic treatment options?

Answer 30

joint rest and ice for acute attack
reduce intake of saturated fat and purines
decrease salt intake
decrease alcohol intake
wt loss and excercise
correct underlying causes (hyperlipidemia and insulin resistance)
smoking cessation

Question 31

What do you use to treat acute gout attacks?

Answer 31

NSAIDS
Colchicine
corticosteroids

Question 32

What do you use to treat chronic management?

Answer 32

Xanthine oxidase inhibitors
uricosurics
pegloticase

Question 33

What it the best time to initiate therapy?

Answer 33

within 24 hours of onset